Humulin R
Defines prior authorization criteria, quantity limits, and coverage duration for Humulin R for Medicaid members of Neighborhood Health Plan of Rhode Island.
No material changes to clinical criteria or coverage were reported.
Coverage Summary
Neighborhood Health Plan of Rhode Island covers Humulin R (regular human insulin) with prior authorization for Medicaid members when the drug is prescribed for a diagnosis of diabetes mellitus and the patient’s daily insulin requirement is > 200 units/day. Coverage is provided for 12 months. Quantity limits are vials: 0.67 ml/day (20 ml per 30 days) and pens: 0.8 ml/day (24 ml per 30 days).
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